PRESCRIPTION REIMBURSEMENT REQUEST FORM Use this form to request reimbursement for covered medications purchased at retail cost. Complete one form per member. Please print clearly. Additional information and instructions on back, please read carefully.

Member Information RxGroup (see ID card) Member ID (see ID card)

Last Name First Name MI

Mailing Street Address Apt. #

City State ZIP

Prescription is for: Self Spouse Dependent Domestic Partner Other_______________________ Gender M F

Date of Birth (mm/dd/yyyy)w

Physician and Pharmacy Information Prescribing Physician Name Dispensing Pharmacy Name

Prescribing Physician Phone Number with Area Code Dispensing Pharmacy Phone Number with Area Code

Reason For Request Select appropriate options for your request:

I did not use my Prescription Drug ID card �I used a non-participating pharmacy (please explain) I filled a compound prescription (your pharmacist must complete section B on the back of this form) Urgent/Emergency visit Prescribed by Dentist I purchased medication outside of the United States

Country Currency used My primary coverage is with another insurance carrier (coordination of benefits claim; see section C on back for details)

I am submitting an Explanation of Benefits (EOB) from another Health Plan or Medicare I am submitting a copay receipt

I was waiting for a drug approval I was retroactively enrolled with the plan My pharmacy billed the wrong plan �Other (please explain)

Acknowledgement I certify that the medication(s) for which reimbursement is requested were received for use by the patient above, and that I (or the patient, if not myself) am eligible for prescription drug benefits. I also certify that the medications received were not for treatment of an on-the-job injury. I recognize reimbursement will be paid directly to me and assignment of these benefits to a pharmacy or any other party is void.

Signature:

Date:

1

2

3

4

_________________________________________________________

_________________________________________________ _______________________________

_________________________________________________________________________________

______________________________________________________________

_________________

ORX5262-KPI_170410

ORX5262-KPI_161208

Instructions for Submitting Form

1. Include the original pharmacy receipt for each medication (not the register receipt). Pharmacy receipts must contain the information in Section A (below). If you do not have pharmacy receipts, ask your pharmacy to provide them to you.

2. Read the Acknowledgement (section 4) on the front of this form carefully. Then sign and date. Print page 2 of this form on the back of page 1.

3. Send completed form with pharmacy receipt(s) to: OptumRx Claims Department, P.O. Box 29044, Hot Springs, AR 71903

Note: Cash and credit card receipts are not proof of purchase. Incomplete forms may be returned and delay reimbursement. Reimbursement is not guaranteed. Claims are subject to your plan’s limits, exclusions and provisions.

Section A – Pharmacy Receipts for Reimbursement

Use the following checklist to ensure your receipts have all information required for your reimbursement request:

Date prescription filled National Drug Code (NDC) number Prescription number (Rx number)

Name and address of pharmacy Name of drug and strength Quantity

Prescribing physician name or ID number

Section B – Pharmacy Information (for compound prescriptions ONLY) (Pharmacist must complete and sign)

• List VALID 11 digit NDC number (highest to lowest cost) in the box at right. Include EACH ingredient

Rx# Date Filled

Days Supply

used in the compound prescription.

• For each NDC number, indicate the metric quantity expressed in the number of tablets, grams, milliliters, creams, ointments, injectables, etc.

• Indicate the TOTAL amount paid by the patient.

• Receipt(s) must be provided with this claim form. * Individual quantities must equal the total quantity. † Individual ingredient costs plus compounding fees

must be equal to the total ingredient costs.

VALID 11 digit NDC# Quantity* Ingredient Cost†

X Signature of Pharmacist

Compounding Fee

Total

Section C – Coordination of Benefits You must submit claims within one year of date of purchase or as required by your plan.

When submitting an Explanation of Benefits (EOB) from another Health Plan or Medicare: If you have not already done so,

submit the claim to the Primary Plan or Medicare. Once you receive the EOB, complete this form, submit the pharmacy receipts, and

attach the EOB. The EOB must clearly indicate the cost of the prescription and amount paid by the Primary Plan or Medicare.

When submitting a copay receipt: If your Primary Plan requires you to pay a copayment or coinsurance to the pharmacy, then

no EOB is needed. Just complete this form and submit the pharmacy receipts showing the amount you paid at the pharmacy. These receipts will serve as the EOB.

Any person who knowingly and with intent to defraud, injure, or deceive any insurance company, submits a claim or application containing any materially false, deceptive, incomplete or misleading information pertaining to such claim may be committing a fraudulent insurance act which is a crime and may subject such person to criminal or civil penalties, including fines and/or imprisonment, or denial of benefits.*

*Arizona: For your protection, Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment or a loss is subject to criminal and civil penalties.

*California: For your protection, California law requires the following to appear on this form: Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

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NONDISCRIMINATION NOTICE

Kaiser Permanente Insurance Company (KPIC) complies with applicable federal civil rights law and does not discriminate on the basis of race, color, national origin, age, disability, or sex. KPIC does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. We also:

Provide no cost aids and services to people with disabilities to communicate effectively with us, such as:

o Qualified sign language interpreters o Written information in other formats, such as large print, audio, and

accessible electronic formats

Provide no cost language services to people whose primary language is not English, such as:

o Qualified interpreters o Information written in other languages

If you need these services, call: 1-866-213-3062 (TTY: 711) If you believe that KPIC has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance by mail or phone at: KPIC Civil Rights Coordinator, 3701 Boardman-Canfield Rd, Canfield OH 44406, telephone number 1-866-213-3062. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 1-800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. _____________________________________________________________________________

HELP IN YOUR LANGUAGE

ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-866-213-3062 (TTY: 711). አማርኛ (Amharic) ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ 1-866-213-3062 (TTY: 711).

.، فإن خدمات المساعدة اللغوية تتوافر لك بالمجانالعربيةإذا كنت تتحدث :ملحوظة (Arabic) العربية (.TTY :711) 3062-213-866-1 اتصل برقم

Հայերեն (Armenian): ՈՒՇԱԴՐՈՒԹՅՈՒՆ. եթե խոսում եք հայերեն, ապա ձեզ անվճար կարող են տրամադրվել լեզվական աջակցության ծառայություններ: Զանգահարեք 1-866-213-3062 (TTY՝ 711):

KPIC-NDTL17-002-SF_Portrait

Ɓǎsɔ́ɔ̀ Wùɖù (Bassa) Dè ɖɛ nìà kɛ dyéɖé gbo: Ɔ jǔ ké m̀ Ɓàsɔ́ɔ̀-wùɖù-po-nyɔ̀ jǔ ní, nìí, à wuɖu kà kò ɖò po-poɔ̀ ɓɛ́ìn m̀ gbo kpáa. Ɖá 1-866-213-3062 (TTY: 711) বাাংলা (Bengali) লক্ষ্য করনুঃ যদি আপদন বাাংলা, কথা বলতে পাতরন, োহতল দনঃখরচায় ভাষা সহায়ো পদরতষবা উপলব্ধ আতে। ফ ান করনু 1-866-213-3062 (TTY: 711)। 中文 (Chinese) 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電1-866-213-3062（TTY：711）。

اگر به زبان فارسی گفتگو می کنيد، تسهيالت زبانی بصورت رايگان برای شما توجه: (Farsi) فارسی تماس بگيريد.TTY) 1-866-213-3062: 711) فراهم می باشد. با

Français (French) ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-866-213-3062 (TTY: 711). Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-866-213-3062 (TTY: 711). ગજુરાતી (Gujarati) સચુના: જો તમે ગજુરાતી બોલતા હો, તો નન:શલુ્ક ભાષા સહાય સેવાઓ તમારા માટે ઉપલબ્ધ છે. ફોન કરો 1-866-213-3062 (TTY: 711). Kreyòl Ayisyen (Haitian Creole) ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-866-213-3062 (TTY: 711). हिन्दी (Hindi) ध्यान दें: यहद आप हििंदी बोलते िैं तो आपके ललए मुफ्त में भाषा सिायता सेवाएिं उपलब्ध िैं। 1-866-213-3062 (TTY: 711) पर कॉल करें। Hmoob (Hmong): CEEB TOOM: Yog tias koj hais lus Hmoob, muaj cov kev pab txhais lus, uas pab dawb rau koj. Hu rau 1-866-213-3062 )TTY: 711(. Igbo (Igbo) NRỤBAMA: Ọ bụrụ na ị na asụ Igbo, ọrụ enyemaka asụsụ, n’efu, dịịrị gị. Kpọọ 1-866-213-3062 (TTY: 711). Italiano (Italian) ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-866-213-3062 (TTY: 711). 日本語 (Japanese) 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-866-213-3062（TTY: 711）まで、お電話にてご連絡ください。 ខ្មែ រ (Khmer) ប្រយត័្ន៖ បរើសិនជាអ្នកនិយាយ ភាសាខ្មែរ, បសវាជំនួយខ្ននកភាសា បោយមិនគិត្ឈ្ន លួ គឺអាចមានសំរារ់រំបរ ើអ្នក។ ចូរ ទូរស័ព្ទ 1-866-213-3062 (TTY: 711)។ 한국어 (Korean) 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-866-213-3062 (TTY: 711) 번으로 전화해 주십시오. ລາວ (Laotian) ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວ ້ າພາສາ ລາວ, ການບໍລິການຊ່ວຍເຫ ຼື ອດ້ານພາສາ, ໂດຍບ່ໍເສັຽຄ່າ, ແມ່ນມີພ້ອມໃຫ້ທ່ານ. ໂທຣ 1-866-213-3062 (TTY: 711).

KPIC-NDTL17-002-SF_Portrait

Naabeehó (Navajo) Díí baa akó nínízin: Díí saad bee yáníłti’go Diné Bizaad, saad bee áká’ánída’áwo’dé̖é̖’, t’áá jiik’eh, éí ná hóló̖, koji̖’ hódíílnih 1-866-213-3062 (TTY: 711). नेपाली (Nepali) ध्यान हदनुिोस:् तपारं्इले नेपाली बोल्नुिुन्छ भने तपारं्इको लनम्तत भाषा सिायता सेवािरू लनिःशुल्क रूपमा उपलब्ध छ । 1-866-213-3062 )TTY: 711( फोन गनुिुोस ्। Afaan Oromoo (Oromo) XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 1-866-213-3062 (TTY: 711). Português (Portuguese) ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-866-213-3062 (TTY: 711). ਪੰਜਾਬੀ (Punjabi) ਧਿਆਨ ਧਿਓ: ਜੇ ਤੁਸੀਂ ਪੰਜਾਬੀ ਬੋਲਿੇ ਹ,ੋ ਤਾਂ ਭਾਸ਼ਾ ਧ ਿੱ ਚ ਸਹਾਇਤਾ ਸੇ ਾ ਤੁਹਾਡੇ ਲਈ ਮੁਫਤ ਉਪਲਬਿ ਹੈ। 1-866-213-3062 (TTY: 711) 'ਤ ੇਕਾਲ ਕਰੋ। Română (Romanian) ATENȚIE: Dacă vorbiți limba română, vă stau la dispoziție servicii de asistență lingvistică, gratuit. Sunați la 1-866-213-3062 (TTY: 711). Pусский (Russian) ВНИМАНИЕ: если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-866-213-3062 (TTY: 711). Español (Spanish) ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-866-213-3062 (TTY: 711). Tagalog (Tagalog) PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-866-213-3062 (TTY: 711). ไทย (Thai) เรยีน: ถา้คณุพดูภาษาไทย คณุสามารถใชบ้รกิารชว่ยเหลอืทางภาษาไดฟ้ร ีโทร 1-866-213-3062 (TTY: 711). Українська (Ukrainian) УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером 1-866-213-3062 (TTY: 711).

اگر آپ اردو بولتے ہيں، تو آپ کو زبان کی مدد کی خدمات مفت ميں دستياب خبردار: (Urdu) اُردو .TTY) 1-866-213-3062: 711) ہيں ۔ کال کريں

Tiếng Việt (Vietnamese) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-866-213-3062 (TTY: 711). Yorùbá (Yoruba) AKIYESI: Ti o ba nso ede Yoruba ofe ni iranlowo lori ede wa fun yin o. E pe ero ibanisoro yi 1-866-213-3062 (TTY: 711).